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Delirium Tremens & Alcohol Withdrawal

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Alcohol is one of the most commonly abused substances worldwide. Alcohol abuse can have negative effects on a person’s physical and mental health, occupation, education, finances, and social welfare. One of the most serious health complications associated with long-term alcohol abuse and alcoholism is that of alcohol withdrawal syndrome (AWS) and delirium tremens (DTs). When someone who is physically dependent on alcohol suddenly quits or reduces use, withdrawal symptoms will emerge, which can range from anxiety and nausea, to more extreme symptoms, such as hallucinations and seizures, which can be fatal. Delirium tremens is a severe form of alcohol withdrawal syndrome. If you are considering quitting alcohol, then you should do so safely under professional guidance.

How Do I Know If I’m Addicted to Alcohol?

Alcohol use disorder (AUD) is another term for an alcohol addiction or alcoholism. It is characterized by compulsive alcohol use regardless of negative consequences. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) reports that about 16 million people in the United States have an alcohol addiction.2 Excessive drinking can lead to physical and social impairments.³ The CDC also reports that excessive alcohol use led to the death of approximately 88,000 people in the USA, from 2006-2010. Alcohol is also responsible for 1 in 10 deaths in the USA, from age 20-64 years.4

It may be difficult to discern whether you or someone you know has an alcohol use disorder. You will want to seek professional assistance to receive an official diagnosis and to best determine the next course of action for treatment, but there are some signs that may indicate that you are addicted to alcohol. The criteria for AUD includes the following signs and symptoms:2,10

  • Consuming more alcohol, or for a longer period of time, than intended.
  • Attempting to decrease or completely quit drinking, but are unable to.
  • Spending a large amount of time drinking or recovering from alcohol abuse.
  • Experiencing strong cravings for alcohol.
  • Consuming alcohol has negatively interfered with family, work, or school.
  • Choosing alcohol over activities that once gave you pleasure.
  • Performing dangerous activities, such as driving, while under the influence.
  • Continuing to drink, despite awareness that it is causing or worsening physical or psychological problems.
  • Developing tolerance, or drinking increased amounts in order to attain the same effect, or realizing that your usual amount of drinks doesn’t have the same effect as it once did.
  • Experiencing withdrawal symptoms when you stop drinking.

It can be difficult to quit drinking once you have developed significant physical dependence due to impending withdrawal symptoms. These withdrawal symptoms can be markedly unpleasant and, in some cases, dangerous—alcohol detox should not be attempted alone.

What Happens If I Try to Quit?

Chronic alcohol abuse can lead to dependence, which means that the body requires the presence of alcohol to function optimally. When a person with significantly severe alcohol dependence dramatically reduces drinking or quits altogether, withdrawal symptoms are likely to emerge. The following symptoms can arise within a few hours to a few days after the last drink:10

  • Insomnia.
  • Anxiety.
  • Increased pulse.
  • Increase respiration rate.
  • Increased body temperature.
  • Increased blood pressure.
  • Hand tremors.

Sometimes there are more dangerous symptoms associated with alcohol withdrawal, especially when left untreated. These include:¹

  • Hallucinations.
  • Seizures.
  • Delirium (disorientation, cognitive and sensory disturbances, changes in consciousness).

There is a general timeline of alcohol withdrawal, although everyone will experience it somewhat uniquely. Withdrawal symptoms often begin within 8 hours of blood alcohol levels decreasing. Generally, symptoms will peak around the third day, and should begin to dissipate within five to seven days.³

Roughly 50% of those diagnosed with AUD will experience symptoms of alcohol withdrawal if they reduce or completely discontinue their alcohol consumption. Of those 50%, about 3-5% experience severe withdrawal symptoms, such as seizures, delirium, or both.³ In addition, up to 60% of alcohol-dependent Intensive Care Unit (ICU) patients are diagnosed with AWS.?

Because withdrawal is often so uncomfortable, many people with an alcohol addiction continue drinking to avoid or relieve their symptoms. However, without professional detox or appropriate medical care, one may develop a more severe and dangerous form of alcohol withdrawal, also known as delirium tremens or withdrawal delirium.

Delirium Tremens Signs and Symptoms

Delirium tremens is the most severe form of alcohol withdrawal, and can cause sudden and dangerous nervous system or mental disturbances.8 DTs develop in up to 33% of patients receiving treatment for alcohol withdrawal syndrome.¹

Alcohol withdrawal delirium symptoms generally emerge within 1-3 days after quitting, but may resolve within 7 days.1 Physical symptoms commonly associated with DTs include:¹

  • Rapid heart rate and increased blood pressure.
  • Insomnia.
  • Excessive sweating.
  • Nausea, vomiting, and diarrhea.
  • Tremors.
  • Weakness.
  • Ataxia (loss of voluntary coordination of body movements).
  • Dysarthria (difficult or unclear articulation of speech).
  • Agnosia (inability to process sensory information).
  • Aphasia (impairment of language).
  • Seizures.

There are also various psychological symptoms associated with DTs. These include:¹

  • Disorientation.
  • Illusions.
  • Hallucinations.
  • Delusions.
  • Irritability.
  • Attention disturbance.
  • Combativeness.
  • Slowed reaction time.
  • Increased startle reaction.
  • Completely or fragmented amnesia.

Up to 4% of hospitalized patients with DTs die. Death may result due to cardiac arrhythmias, withdrawal seizures, hyperthermia, or co-occurring medical conditions.³ DTs may be mitigated by understanding the risks, and getting treatment early.

Risk Factors

Not everyone who is withdrawing from alcohol experiences delirium tremens; some people are more susceptible to DTs than others. There are a few factors that increase the risk of experiencing severe withdrawal or delirium tremens. These include:1,9

  • Older age.
  • Poor liver function.
  • Nutritional status.
  • Prior history of DT.
  • History of alcohol withdrawal seizures.
  • Long-term, heavy drinking.
  • Presence of other medical problems, such as infectious diseases.

In some cases, people who develop alcohol withdrawal delirium may have other health issues that will require additional medical attention, including:1,10

  • Pneumonia.
  • Gastrointestinal bleeding.
  • Liver failure.
  • Dangerously low blood sugar.
  • Electrolyte imbalance.
  • Wernicke-Korsakoff syndrome, a dangerous brain condition.

Attempting to quit on your own can have detrimental, or even fatal, effects. However, there are safe and healthy detox methods that can be conducted under the guidance of a medical professional.

Delirium Tremens Treatment

Those who have developed an addiction to alcohol may experience AWS or DTs if they suddenly stop drinking, or significantly decrease their drinking. This condition can be fatal if left untreated. The following tests and interventions may be conducted and administered in the hospital for those experiencing DTs symptoms:1,3,8

  • Physical exam, to assess for body temperature, pulse, breathing rate, fluid status, and blood pressure.
  • Lab tests, such as serum electrolyte levels, a full blood panel, toxicology screen.
  • Electrocardiogram or ECG, and an electroencephalogram or EEG.
  • Sedatives and/or other medications are used to prevent and manage dangerous symptoms and complications.
    o Benzodiazpines are considered a mainstay medication of DTs treatment. They are typically effective in preventing and treating seizures and withdrawal delirium. You will receive a fixed schedule with gradual dose reduction over a predetermined period of time.
    o Antipsychotic drugs, such as haloperidol, may be used in conjunction with benzodiazepines.
    o Propofol may also be used when the other drugs alone are ineffective at managing delirium.
  • Vitamins (e.g., thiamine, b12), fluid, electrolyte, and glucose replacement, if needed.
  • Provide supportive care in a quiet, calm, and caring environment for the patient.

The major goals for the treatment of DT include:3,8

  • Control agitation.
  • Reduce the risk of seizures.
  • Reduce the risk of injury.

Substance Abuse and Mental Health Services Administration (SAMHSA) recommends 24-hour monitoring and support when detoxing from alcohol. The setting should also be appropriate for both the medical and psychological conditions present, and should offer medical monitoring as needed. If the physical conditions are life-threatening, then hospitalization in the intensive care unit (ICU) for acute monitoring may be necessary.9 This is due to safety and humanitarian concerns associated with alcohol withdrawal syndrome. Around-the-clock detox can be completed in a hospital setting or at an inpatient psychiatric or substance abuse treatment facility.3

If you have a history of heavy, chronic drinking and are thinking of quitting alcohol use, the safest course of action is to seek formal detox treatment before suddenly stopping so that you can quit under professional supervision. If you are currently experiencing symptoms of delirium tremens, call 911 immediately, as it is a medical emergency.

Alcohol Abuse Treatment

Detoxification, although a beneficial and life-saving process, is not a substitute for comprehensive alcohol abuse treatment because it doesn’t address the underlying factors that drive alcohol abuse. Once detoxification is completed and you’ve been medically stabilized, it’s important to seek the help of an addiction treatment program, particularly for someone who has experienced DTs because they are likely to have a severe addiction. Alcohol abuse treatment programs can help patients to replace negative coping skills with healthier ones, rectify maladaptive behaviors, increase sober social skills, and learn relapse prevention strategies to help them stay sober in the long run. Substance abuse treatment can occur in a variety of settings:

  • Inpatient facility: Treatment may include individual therapy, group counseling, mutual-support groups, and alternative therapies while you stay in a residential facility.
  • Outpatient facility: Treatment is similar to that of inpatient, however on an outpatient basis. You are able to continue working or attending school, if need be.
  • Luxury facility: Likened to an all-inclusive resort vacation, this expensive treatment option combines therapeutic services, such as counseling, with upscale amenities. Each program varies, but amenities may include, private room, gourmet meals, acupuncture treatments, fitness coaching, pool, gyms, horseback riding, golf, yoga classes, and nutritional counseling.
  • Executive facility: Catered towards high-profile working professionals and their demanding schedules and lifestyle, these inpatient programs typically provide access to a business center, a higher staff-to-patient ratio, personalized meals, exercise facilities, higher privacy standards, private rooms, and spa services.
  • Holistic facility: These inpatient facilities focus on the mind-body-spirit connection, working to heal and strengthen each of these areas. They may offer healthy meals, physical activities, meditation, yoga, tai chi, massage, acupuncture, psychotherapy, and a scenic location either in the mountains or near a body of water.
  • Population-specific programs: Catered and designed for treatment of a specific population, such as teens, veterans, men-only, women-only, and LGBT, these programs address the unique needs associated with these various groups.

If you, or a loved one is suffering from alcohol abuse, help is available. With the right treatment, both recovery and a lifetime of sobriety are within reach.

Sources

  1. Biomed. 2015. Alcohol withdrawal delirium – diagnosis, course and treatment.
  2. National Institute on Alcohol Abuse and Alcoholism (NIAAA). 2017. Alcohol Use Disorder.
  3. The New England Journal of Medicine. 2014. Recognition and Management of Withdrawal Delirium (Delirium Tremens).
  4. Centers for Disease Control and Prevention. 2016. Fact Sheets – Alcohol Use and Your Health.
  5. National Institute on Alcohol Abuse and Alcoholism (NIAAA). 2016. Alcohol Use Disorder: A Comparison Between DSM–IV and DSM–5.
  6. Bayard M, McIntyre J, Hill KR, et al; Alcohol withdrawal syndrome. Am Fam Physician. 2004 Mar 1569(6):1443-50.
  7. Don-Kelena Awissi, Genevieve Lebrun, et al; Alcohol withdrawal and delirium tremens in the critically ill: a systematic review and commentary. SpringerLink. January 2013, Volume 39, Issue 1, pp 16–30.
  8. MedlinePlus. 2017. Delirium Tremens.
  9. Substance Abuse and Mental Health Services Administration (SAMHSA). 2013. Detoxification and Substance Abuse Treatment- A Treatment Improvement Protocol.
  10. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

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